Case Presentation: Ill-appearing and Tachypneic 23-year-old
Midway through your shift, a 23-year-old woman arrives by EMS. She is ill-appearing, tachypneic, and has a distinct odor you recognize as ketones. Her bedside glucose is 680 mg/dL. You suspect DKA, but wonder what led to it.
You know that starting insulin and fluids is indicated, but you wonder whether insulin should be administered as an IV bolus, whether insulin should be given before or after IV fluids, what fluids are most appropriate, or whether you should just proceed with subcutaneous insulin.
As if these questions were not enough, your first-year resident tells you the patient has a pH of 7.1 and asks if she needs sodium bicarbonate. He also asks if she should be intubated, since she is breathing so hard?
The young woman?s medical record showed she had been admitted 4 times in the past year with DKA. You recognized that recurrent cases are often due to insulin noncompliance, and indeed the patient admitted she had not been taking her insulin because she thought it caused her to gain weight. Still, you looked for other underlying causes, including pregnancy and infections. You decided not to bolus her insulin because you knew it does not have any proven benefit. You knew she was not an appropriate patient for subcutaneous insulin administration due to her severe acidosis.
You started her on a balanced electrolyte solution with the intent to avoid possible iatrogenic hyperchloremic metabolic acidosis that can be associated with normal saline. You did not give her any sodium bicarbonate when her pH resulted at 7.1. You decided against intubation because you knew her work of breathing was an effort to generate a respiratory alkalosis to offset her metabolic acidosis and you knew you would have difficulty matching her pre-intubation minute ventilation on a ventilator. You admitted her to the ICU, where she had an uneventful recovery.
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